HospitalInspections.org

Based on review of the emergency room log, review of electronic medical records, staff interviews, and policy review, the facility failed to log 1 of 20 sample patients (#7) reviewed. The findings were:

1. Review of the emergency room log from 8/1/21 to 4/28/22, failed to show evidence of patient #7 being logged in the emergency room central log. Review of the electronic medical records failed to show patient #7 received medical care. The following concerns were identified:

a. Interview on 4/29/22 at 9:56 AM with RN #1 revealed she worked as the medical screener on 8/5/21 when the patient presented to the emergency department (ED). She stated the patient told her s/he had been in a motor vehicle accident and needed to be seen. She also stated when she asked the patient to put a mask on, the patient stated s/he was having difficulty breathing and chest pain and could not wear a mask. The patient requested to speak to the charge nurse.

b. Interview on 4/29/22 at 10 AM with RN #2 revealed she was the charge nurse on the day the patient presented to the ED. She further stated she talked with patient, who told her s/he absolutely could not wear a mask due to difficulty breathing and chest pain. She stated she offered to let the patient come into the ED without a mask. She further stated the patient refused to go in unless the 2 people who were with him/her could go in. She explained only the person being seen could go into the ED.

c. Interview on 4/29/22 at 10 AM with both RN #1 and RN #2 revealed the ED manager also talked with patient #7. However the patient left without being seen. They both stated they asked the manager how they should log the encounter because the patient did not give a name. They both confirmed the encounter was not logged because the patient did not give a name.

2. Review of policy "EMTALA" revised on 9/26/2019, confirms, "CRMC maintains a central log of each individual who comes to CRMC seeking emergency assistance and whether he or she ...left without being seen, refused examination or treatment ...".